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This short questionnaire was developed to help the IMF learn more about problems patients have experienced in attempting to receive the best possible treatment for multiple myeloma.

The questionnaire is easy to complete, usually requiring only YES/NO answers, it shouldn’t take you more than 10 minutes to complete.

If you are completing the questionnaire on behalf of a myeloma patient, please answer all questions as the patient would.

Patient Access Questionnaire
Questions that require an answer are marked with  *
   
1 * Are you a Medicare patient or a patient covered through Medicare Advantage plans?
   
   
2 * Have you EVER had a problem getting the myeloma treatment your doctor thought you needed?
   
   
3 * Have you EVER been told by your doctor that he/she would like to give you treatment X for your myeloma but that your health insurance doesn’t cover treatment X?
   
   
4 * Has your doctor EVER told you that your plan doesn’t cover treatment X at that particular point in your disease?
   
   
5 * Have you EVER had to make the decision that you could not pay for the treatment your doctor recommended because the co-pay was more than you could afford?
   
   
6 * Have you EVER applied for co-pay assistance?
   
   
7 If you answered "NO" to the previous question, please skip to Question 10. Otherwise:

When you applied for co-pay assistance, were you:
   
   
8 If you answered "Successful" to the previous question, please skip to Question 10. Otherwise:

Why were you unsuccessful?
   
   
9 Was the co-pay assistance you received:
   
   
10 * Have you EVER had to make the decision to stop taking a myeloma treatment regimen because of the Medicare doughnut hole?
   
   
11 * Have you EVER decided not to start a myeloma treatment regimen because when you went to the pharmacy to fill the prescription, you simply couldn’t afford to have it filled?
   
   
12 * In trying to get a particular treatment approved for funding reimbursement, has it EVER taken you so long to complete the paperwork and for it to be processed for approval that it delayed your starting the treatment for:
   
   
13 * Has your insurance provider ever made it difficult for you to get the
therapy your doctor was recommending by stating that the recommended therapy
was not approved in your situation, even though you and your doctor thought
it was?
   
   
14 Do you have a specific personal story you would like to tell us about difficulties you have had in gaining access to appropriate care? If so, please use the space below:
   
   
If you need additional space please email your story to: mystory@myeloma.org
   
   
15 * Full Name
   
   
16 * Email Address
   
   
17 * Telephone Number
   
   
18 Do you wish to remain anonymous? If so, we will run your story with a fictitious name.
   
     
12650 Riverside Drive, Suite 206 | North Hollywood, CA 91607-3421 | USA
Hotline: 800-452-2873
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